Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some truly remarkable people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding. 

For years, people have been asking me about a communication strategy called the teach-back technique. Today, I am delighted to be talking with creators of a new, free, interactive, online toolkit called Always Use Teach-back. I have three guests today.

The first one is Dr. Mary Ann Abrams, who is a physician who led the development of Health Literacy Iowa, Iowa’s statewide center for literacy, and the Iowa Health System’s Health Literacy Quality Initiative. Mary Ann Abrams also authored and edited many health literacy publications and led numerous health literacy initiatives.

The second guest is Suzanne Rita, who is a nurse, an educator and the Improvement Learning Network Manager for Iowa Health System, where she mentors improvement teams and serves as an advisor to system-wide efforts in achieving results.

Gail Nielsen is our third guest. Gail is director of Learning and Innovation at Iowa Health System. She also is a fellow, faculty member and Patient Safety Scholar at the Institute for Healthcare Improvement.

Welcome, everyone. The three of you are all in one place and I’m in another, so let’s take this one by one. Maybe we can start with you, Mary Ann. You are such a long-term champion of using the teach-back technique. Can you briefly recap or teach us what the technique is and why people should always use it?

Mary Ann: Thanks, Helen. Teach-back is such a great technique. Quite simply, it’s a way to make sure that we as healthcare providers have explained information clearly to both patients and their family members or other caregivers and have asked them to explain it back to us in their own words so that we know that we’ve done a good job explaining it clearly.

Helen: Let’s try this. The teach-back technique means I have to say it in my own way. Is that right?

Mary Ann: If you are the patient, yes. When you say it in your own words, that means you’ve really understood what we have said and asked you to do or remember. That way, I know I was clear. I put that responsibility for being clear on my shoulders when I ask you to explain it back.

Helen: The teach-back technique is quite the buzz. It’s catching on, but why is it that important that people should always do it? When I say people, I mean the professionals in a conversation, correct?

Mary Ann: We recommend that teach-back be used for any important communication in the healthcare setting.

Clearly, the clinical team should be using it, including doctors, nurses, respiratory therapists and social workers who are helping with discharge planning, but also people who may be working at the front office that are helping to make sure people know how to get to a referral appointment or a follow-up lab test.

Helen: We all should be double or triple checking that what we said came out and was understood. I know that in the tool you had, you call it Always Use Teach-back. What is that “always” part about?

Mary Ann: That is one of the things that we think is really special about the concept of always using teach-back. The Picker Institute, which helps support some of this work, defines an Always Event as an aspect of patient and family care that should always occur when a patient or family interacts with the healthcare setting in the delivery system.

As opposed to our focus sometimes on Never Events, an Always Event is something that should always happen. We believe teach-back should be an Always Event to help promote adherence to medication safety and follow up for quality and other important health information.

Helen: I’m getting this, Mary Ann. This is something that we always need to be doing. You are one of the creators of this new toolkit. How does that help?

Mary Ann: We’re excited because the toolkit includes several features that we think will help people who are using or want to use teach-back in their setting on a routine Always basis.

One part of that toolkit is the interactive learning module. The neat part about that is that it gives learners the chance to follow Sharon, a woman who is going home from the hospital with a diagnosis of diabetes.

It follows her from hospital discharge to her home-health visit and follow-up appointment with her primary care physician. We really get to look at consistent, plain language and use of teach-back messaging throughout the care continuum, especially during those critical transitions between healthcare settings.

Helen: That sounds fabulous. Can you give us the URL? We’ll put it on the Health Literacy Out Loud website.

Mary Ann: It is www.TeachBackTraining.com.

Helen: Thank you so much. Maybe we should move on to some of these how-tos. What do we do? What can we know? How can we use this toolkit? Are people really doing this in practice? I want to know it all. Suzanne, maybe you can clue us in.

Suzanne: We were also very interested in learning the answer to those questions. When we talked with our staff, they were telling us that they were using teach-back.

Because we weren’t going to make any assumptions about what it was like to teach these patients in all of our healthcare settings, I set out on a mission to do some observations around the use of teach-back in our acute care hospitals, our homecare setting and in physician practice.

Helen: People said they were doing this, but you said, “Let me just look at that again.”

Suzanne: Exactly. We were looking for if our staff was actually using teach-back in the way that teach-back should be used, which is giving our patients and family the opportunity to teach back to us in their own words how they understood what we said to them.

Helen: You were observing other people doing this. What did you find?

Suzanne: What I found was that 20% of our staff was actually using teach-back, but there was 80% of our staff that thought they using teach-back, but they actually were not.

Helen: What were they doing?

Suzanne: They were asking patients yes-no questions.

Helen: That’s not part of the teach-back?

Suzanne: No, part of teach-back would be to ask the patients open-ended questions so that we can better understand what they understand.

Helen: That must have been a real aha moment for you and for them. Did you clue them in that this wasn’t really teach-back?

Suzanne: Absolutely. The other thing that was a big aha moment for us while we were doing the observations was that when all of our staff was teaching patients or their families, they taught them using the same technique every single time.

If one of the nurses was teaching a patient that was going home with heart failure, she would always ask the patient, “Do you understand?” There would be another nurse who would always ask the patient, “Do you have any questions?”

Helen: Neither one of those are really effective questions.

Suzanne: That’s right. What I learned was that they always used the same yes-no questions.

Helen: They were in the habit of it.

Suzanne: Absolutely. That was a huge aha moment for us. This actually was a habit.

Helen: Because most people weren’t really doing teach-back, and I assume that you want to make it an Always Event, how do you create this to be a new habit?

Suzanne: That was a question that we also wanted to learn more about. We went ahead and developed the teach-back toolkit, most particularly the interactive training module that you and Mary Ann have already talked about.

We showed that to all of our staff that was involved in the study. We wanted to make sure that the staff truly understood the real meaning of teach-back. After they saw the interactive teaching module, I went and did some observations with them and then coached them.

Helen: You coached them. It wasn’t like you just said, “Watch this. Do it.”

Suzanne: Exactly. I did not.

Helen: What’s that coaching part all about?

Suzanne: After they saw the education, we would go into a room together and they would have the opportunity to teach-back with patients and families. How quickly my coaching would help them to move to a new habit depended on which healthcare provider I was with.

There was some staff I worked with that would go to teach a patient and ask a yes-no question. We would walk out of the room and have some conversation around, “Do you know exactly what you wanted the patient to know? Were they able to teach that back to you?” They would say, “No. How could you ask that question differently?”

Then we would actually rehearse how they could ask the question differently so that the next time they would be teaching a patient and I would be observing them, they would use an open-ended question.

Helen: Were people open to this kind of feedback and coaching?

Suzanne: Most of the healthcare providers were. We did have one that really had a difficult time changing, so we worked with that staff member over a period of several months using this technique.

We said, “What is the most important thing you want the patient to know? How will you know that the patient knows that? What kinds of questions will you ask?” Those were all of the coaching questions that we would ask before the teaching took place. Afterward, we would also ask those kinds of questions.

Helen: It sounds like you are not only coaching for teach-back, but you’re coaching about how to teach. What are the key points? What are you trying to say? How are you saying it?

Suzanne: Certainly. If you’ve ever had the opportunity to observe staff while they are teaching patients, there are a lot of things that we talk to our patients and families about. Teaching them is all throughout their care.

We’ve told the patient so many things that we want them to know, but what is the most important thing that they need to know right now to care for themselves between this visit and the next visit? We really focus in on using teach-back.

Helen: That’s great. I’ve been in a lot of patient education roles myself, and I know how hard it is to change habits. I know how concerned people are about time too. Is this a pretty efficient method of helping people go from one type of behavior and communication style to another?

Suzanne: It does take time. There is no doubt about it.

Helen: What kind of time are we talking about, minutes, weeks or months?

Suzanne: It really depends on the learner and how eager they are to change their habits.

We also know that if patients and families are not able to teach-back, there are a lot of complications that could be associated with that. Taking the time now is the most beneficial thing for our patients and families so that they will be able to care for themselves while they are not in the hospital or physician’s practice.

Helen: Thanks. This is really interesting. I looked around your site a lot. It is filled with so many things. Your role in the organization is also looking at system-wide practices. You’re talking about teaching, helping or coaching one person at a time. Is this supported by policy, practice or standards system wide?

Suzanne: As a system, we are dedicated to using teach-back when we have conversations with all of our patients and families.

We have begun to use not only the teach-back toolkit as a vehicle to teach our staff to use teach-back, but we also use the coaching module that is on there to help the people that will be coaching them  become more efficient coaches.

Helen: The way you’re putting it together at the individual level and at the bigger systems level is great. Is this something that you feel other organizations can take on too?

Suzanne: Certainly. When you look at the toolkit, we have put it together that way. If you are an individual learner and come to the site and want to learn about teach-back, you can. If you are a bigger organization that wants to teach about teach-back, plus help your staff to become coaches, we have that available too.

There are coaching tips that we have put on the site. There are also the observation tools that I use, so you could actually go out there and be able to see exactly what teach-back looks like in your organization.

Helen: That’s great. I recommend all listeners go take a look at that site. Find that URL. It will be on our website. We’ll mention that again.

Hi, Gail.

Gail: Hi, Helen.

Helen: You and I have known each other since way back when health literacy was just emerging as an issue. We’re both hanging in there doing all of this. I heard your excitement about this toolkit. Having looked around and in talking with all of you, I share your excitement about it.

What would you most want the listeners of Health Literacy Out Loud to know about this toolkit that we haven’t already covered?

Gail: Helen, there are a few things that I would love for people to know. One is that we have been asked for the past few years from teams across the nation working on improving care coordination or other kinds of intervention like reducing avoidable readmissions, “Instead of developing our own internal education, do you have something we could get started with?”

We’ve had this idea in our mind for quite a long time, and here it is. It is for a couple levels of learners. First of all, it is for those individuals who just want to learn how to use teach-back in three settings: in the hospitals, the office practice and the home with homecare providers.

Also, it is helpful to those people who may be trying to get all of their staff, whether it is an office practice, homecare or hospital, to use this as often as they should in their setting.

We want to make sure that they know how people can develop habits. As Suzanne was describing, this is really a challenge to start to do something new in our work because everyone is so busy in their care settings now.

The second level of learning is how do we help their coaches, managers, nursing executives, physician managers or leaders build these new habits as everyday work?

It helps with the very beginning of getting started, but as the tool gets out there into many hands, what we’re finding is that it’s also helpful to those people who have been doing teach-back for years but find it’s not reliable because the habits were never built.

The tools in this toolkit actually help people learn how to figure out whether it is happening, what might be missing and what they need to coach to. Then it helps them measure over time if they can improve the reliability.

Helen: Give us the URL again.

Gail: The URL is www.TeachBackTraining.com.

Helen: That’s perfect. Gail, I know with all of your work with the Institute for Healthcare Improvement and all of that, you have such a big vision. This toolkit seems like it is meeting people’s needs wherever they are. That is really the essence of health literacy.

As a result of this toolkit, what do you hope will happen?

Gail: We hope that teach-back becomes used everywhere around the globe. I’ve had a chance to teach in Ireland and London with other people from IHI around the globe. What we’re finding is that the same problem exists everywhere.

This is a really important technique for people to learn early in their career when they’re coming up to their education programs and in the course of their work today because it really can help transform care.

We’re seeing that the government is even getting in on this now. There actually is a national action plan saying that health literacy needs to come out of the background into the foreground and become real in our regular work.

We see it as a worldwide need. People in many settings are getting to use it now. The people I was just working with in Dublin a week ago are very excited about using this tool as well and want me to talk more about how they would do some of the coaching,

Helen: This is wonderful. Our listeners are worldwide as well.

I want to thank the three of you for helping to lead the way in teaching us as individuals, teams, organizations and the great, big, wide world to make sure and confirm that people really do understand what we are communicating. Thank you so much to the three of you.

Gail: Thanks, Helen.

Helen: I learned so much about teach-back from Mary Ann Abrams, Suzanne Rita and Gail Nielsen. I certainly hope, and even expect, that you did too, but health literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com.

While you are there, sign up for the free enewsletter, What’s New in Health Literacy Consulting. New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, Stitcher Radio and the Health Literacy Out Loud website at www.HealthLiteracyOutLoud.com.

Did you like this podcast? Did you learn something new? If so, tell your colleagues. Tell your friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.